CurrentBlue Cross Blue Shield - TexasPolicy CPCPLAB044

Lyme Disease Testing

This policy defines Blue Cross Blue Shield of Texas reimbursement criteria for laboratory testing to diagnose Lyme disease, including when serologic testing, PCR, and other tests are reimbursable or not, and applies to providers submitting claims under BCBSTX plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeAdministrative — code added

Effective DateAug 1, 2025

Next Review Date

Key ActionSubmit accurate documentation and code claims using valid HIPAA‑approved code sets; claims are subject to plan documents and clinical payment and coding policies.

SourceLink

POLICY UPDATE CHANGES

Added code 0580U effective 10/01/2025.

8listed procedure codes

2-tierpreferred serologic testing strategy

14PCR recommended window (days)

7non‑reimbursable serology situations

10/01/2025plan / code effective

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyLyme Disease Testing

Policy CodePolicy CPCPLAB044

Change TypeAdministrative — code added

Effective DateAug 1, 2025

Next Review Date

Key ActionSubmit accurate documentation and code claims using valid HIPAA‑approved code sets; claims are subject to plan documents and clinical payment and coding policies.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria for diagnostic testing for Lyme disease

Reimbursement criteria for Lyme disease laboratory testing

ALL of the following

Serologic testing indication
- Individual has symptoms of Lyme disease and a history of travel to a region endemic for Lyme (with or without history of a tick bite); serologic testing using a 2-tier strategy (sensitive EIA or immunofluorescence assay followed by Western immunoblot or FDA-cleared second EIA) may be reimbursable.
- Specific clinical syndromes: For individuals with a history of travel to an endemic region, serologic testing using a 2-tier strategy may be reimbursable for any of the following: (a) acute myocarditis or pericarditis of unknown cause; (b) meningitis, encephalitis, or myelitis; (c) painful radiculoneuritis; (d) mononeuropathy multiplex (including confluent); (e) acute cranial neuropathy.
PCR in neurologic window: Polymerase chain reaction (PCR)-based direct detection of B. burgdorferi in CSF may be reimbursable and may replace serology for patients with short-duration (<14 days) neurologic symptoms during the antibody window period.

ALL of the following

ANY of the following
- Individuals with an erythema migrans (EM) rash — treat clinically rather than serologic testing.
- Asymptomatic patients living in endemic areas (screening).
- Individuals with non-specific symptoms only (e.g., fatigue, myalgias/arthralgias).
- Individuals with amyotrophic lateral sclerosis (ALS).
- Individuals with relapsing-remitting multiple sclerosis.
- Individuals with Parkinson's disease.

ALL of the following

Repeat serologic testing is not reimbursable for individuals who have previously tested positive for Lyme disease.
All other testing for Borrelia burgdorferi not described in this policy is not reimbursable.
Testing of the tick for diagnosis of Lyme disease is not reimbursable.

ALL of the following

Not all requirements apply to each product; providers should review plan documents for eligible coverage.

Listed Lyme Testing Codes

Listed Lyme testing codesmixed

86617	Lyme disease antibody test (Borrelia burgdorferi) IgG
86618	Lyme disease antibody test (Borrelia burgdorferi) IgM
87475	Infectious agent antigen detection by nucleic acid (e.g., PCR) for Lyme
87476	Infectious agent detection by nucleic acid, second Lyme-related code
0041U	Proprietary Lyme-related molecular/serologic assay (per policy code list)
0042U	Proprietary Lyme-related molecular/serologic assay (per policy code list)
0316U	Proprietary Lyme-related assay (per policy code list)
0580U	Newly added proprietary Lyme-related assay code effective 10/01/2025

Listed Lyme testing codes (compact list)mixed

86617	86617
86618	86618
87475	87475
87476	87476
0041U	0041U
0042U	0042U
0316U	0316U
0580U	0580U

Documentation and Claims Submission

Documentation Required

Documentation, coding and plan‑document applicability

Providers must submit accurate documentation of services performed and code claims using valid HIPAA‑approved code sets; claims should be coded according to industry standard coding guidelines (for example, UB, AMA CPT, HCPCS, ICD‑10, NDC, DRG guidelines, CMS NCCI policy manual and table edits). Claims are subject to code edit protocols, claim review, provider contract language, plan documents, clinical payment and coding policies, and coding software logic; upon request providers should submit additional documentation. Not all lab management reimbursement requirements apply to every product—providers must review the applicable plan documents for coverage eligibility.

Submit claims using valid code combinations from HIPAA‑approved code sets and industry standard coding guidelines.
Be prepared to provide additional documentation upon request to support medical necessity and coding.
Review member’s plan documents and provider contract language because plan documents or contracts govern in the event of a conflict and not all policy requirements apply to each product.

Definitions and Testing Strategies

inv-04: 2-tier testing strategy

DefinitionTwo-tier testing strategy: initial sensitive enzyme immunoassay (EIA) or immunofluorescence assay (IFA) followed by a Western immunoblot assay or an FDA-cleared second EIA.

When reimbursableMay be reimbursable for individuals with symptoms of Lyme disease and history of travel to an endemic region (with or without known tick bite).

Additional reimbursable indicationsMay be reimbursable for individuals with history of travel to an endemic region who have acute myocarditis/pericarditis of unknown cause, meningitis/encephalitis/myelitis, painful radiculoneuritis, mononeuropathy multiplex (including confluent), or acute cranial neuropathy.

inv-05: PCR-based direct detection of B. burgdorferi in CSF

DefinitionPolymerase chain reaction (PCR)-based direct detection of Borrelia burgdorferi in cerebrospinal fluid (CSF).

Scope of useMay be reimbursable and may replace serologic documentation of infection for patients with short-duration (<14 days) neurologic symptoms during the antibody window period between exposure and detectable antibodies.

LimitationsApplies specifically to CSF specimens; not a replacement for serology outside the indicated short-duration neurologic presentation per policy.

Related policy noteAll other testing for Borrelia burgdorferi not described in the policy is not reimbursable; testing the tick is not reimbursable.

OpenPayer

Lyme Disease Testing

Coverage Criteria for Lyme Disease Testing

Listed Lyme Testing Codes

Documentation and Claims Submission

Definitions and Testing Strategies